Bad Directions

I love the GPS analogy for health care. Patients need a GPS for their health, showing them the reality of their past, present, and future health. The analogy has not only shown me how I want to give care for my patients, it has also given me insight into the pitfalls of automated medical care.

Way back in the days when GPS was new, the rental care company Hertz advertised “NeverLost,” a GPS on your dashboard (if you forked out the extra money for it). I was asked to give a talk in Oregon, and decided I would try out this cool new technology (since others were picking up my bill). While I found it overall very useful, there were a couple of times it didn’t work as advertised.

I needed a sweatshirt, so I used the NeverLost for directions to a Wal-Mart. It worked! It gave me flawless directions to a Wal-Mart store…in Las Vegas (over 1000 miles away). I stopped at a gas station and they told me that there was actually a Wal-Mart 1/2 mile down the road.

Then, when I was trying to get to Crater Lake, “Never Lost” repeatedly directed me down dirt roads, some of which had trees fallen across their path. NeverLost was quite perturbed when I didn’t follow its direction, nagging me to make an immediate u-turn back toward the tree in the road.

Lest you think this is a problem unique to the early days of GPS, let me tell you about a more recent (and more expensive) GPS mishap. While in Northern Michigan on vacation I asked for directions using the GPS on my phone. It directed me down another dirt road, complete with deep ruts for tires which made my car scrape its underside on a dirt-rock potpourri, doing damage to my catalytic converter and costing me several hundred dollars. (I have subsequently decided to ignore all dirt road directions).

Clearly lot of primary care can be delivered without doctors. But how much do we really need the nurse? If a nurse can type in my answers to questions and follow a decision tree, why can’t I do that myself? If the nurse’s advice is largely read off a computer screen, why can’t I read the advice myself?

What about the hands-on activities? Patients can already take their own blood pressure. In fact you can do it yourself inside the CVS pharmacy. If the health care system were not so dominated by third-party payer bureaucracies, I suspect my iPhone would already have a stethoscope app. If my iPhone can easily identify a piece of music playing in a local bar, how hard would it be to create an app that interprets stethoscope sounds? As for the ENT observations, couldn’t an app do that as well?

The article recounts a visit to a MinuteClinic in which Goodman’s care was menu-driven and automated, prompting him to muse about the people taking his money to do a task that he could do without them. This makes me nervous since he is, to some degree, saying I can be replaced by a computer. Forget about “to some degree,” he finishes with a flourish:

Finally, there is the matter of the prescription my nurse e-mailed to the pharmacy. If she is just following a protocol, why do we need the nurse? Why can’t I do it myself? Or more precisely, why can’t I authorize the computer to mail in the prescription the same way the nurse does?

Here’s my prediction: Within five years we’ll all have MinuteClinic decision trees on our personal laptop computers.

Wow. Is he right? I used to think MinuteClinics would hurt my business, but having my patients completely avoid care altogether seems a legitimate threat to the future of my primary care.

The outcry from primary care physicians on this is inevitable, as Goodman threatens the very heart of the our business model. The only way I am paid is when my patients come to my office in person, so I bring patients in for whatever care possible. Patients using smart phones and computers to avoid my office seem to spell my doom as a PCP. Should we arise as PCP’s and defend this turf? Or would that amount to holding on to an outdated business model, much as the record industry held to its monopoly on music distribution with the advent of digital music?

But I think Goodman is right that the direction toward this is inevitable, and so, instead of mimicking the music industry and trying to argue for an outdated model, we should carve out a new role in patient care This role addresses the weaknesses of MinuteClinics, computerized care, and GPS devices. My GPS follies underline two important facts about directions given by technology:

1. Technology can give bad directions.

For a GPS, this becomes apparent when facing a tree in the road or a bill from your car repair shop Consequences of bad medical directions may be much more serious, raising expense and even causing injury or death. But bad directions doesn’t keep me from using a GPS; instead, I use the GPS as part of the solution, not the whole. The best directions come from mixing GPS directions with knowledge of people who know the roads and can give directions from personal experience.

In the past, my patients relied entirely on me for all of their medical direction. They were largely in the dark about care, and could not get information from any other source. So I ended up giving them turn-by-turn directions, nagging them whenever they chose to go another route. The Internet changed everything, giving them access to both factual information and advice. Is that really a bad thing? Do I really want to tell my patients things they could read on their own? Do I really want to force them to come to my office for things they could get without me? Why not instead take on the role of the friendly local who knows the roads better than the GPS?

2. Technology can give directions that lack perspective.

I recently saw a woman in the office who got an antibiotic for “bronchitis” (i.e. A loose cough, likely caused by a virus) from another physician. Two days after starting her antibiotic she developed severe diarrhea and abdominal cramps. She was a sick pup, presumably with colitis caused by Clostridium Difficile, a nasty bug that likes to take over the colon when other bacteria are killed off by broad-spectrum antibiotics. Experience tells me that she probably would have gotten over her “bronchitis” without any antibiotic, sparing her the pleasure of abdominal cramps and near-dehydration (not to mention the joy of Flagyl, the nasty antibiotic I had to prescribed for her colitis).

The other physician was addressing her immediate concern, the loose cough, not considering the big picture of her health. This is like the GPS sending me to Las Vegas to buy a sweatshirt at Wal-Mart. Technology (and the MinuteClinic) doesn’t have to live with the consequence of its advice.

So what should primary care be in this post-GPS era? I think primary care has made itself far too small: becoming the treaters of coughs, the followers of protocols, and the keepers of the patient record. In truth, I would gladly give up these mundane jobs, and fear my professional societies will fight for my right to hold on to them. Primary care physicians are not simply “non-specialists;” we have a unique position in care – one that is growing in its importance with impending reform.

We have a long-term relationship with our patients. We know them as well as anyone, and so can give advice based on that personal knowledge, and will be by their side with the consequences of their medical decisions, good or bad.

We have a unique position of communication. We can explain the GPS results, keeping them out of danger and explaining the best path to everyone’s goal: lots of birthdays.

We are neutral. I don’t get paid more (like the specialist, drug company, or hospital) when my patients utilize our system. I don’t benefit when my patients get sick. I want to keep them around for a long, long time, caring for their children and grandchildren.

Instead of fighting this change in direction, let’s embrace the chance to go down a new road. It seems like a much better direction to me.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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Rob,
Excellent post. There future lies in following this and not being tied down by the reimbursement system.
I just started a Direct pay practice in Houston http://www.integratedhealth.us to address these concerns. It is off to a decent start so far

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kbcabezon

Aug 14, 2012

Rob – great post. From your second point, “I don’t get paid more (like the specialist, drug company, or hospital) when my patients utilize our system” I’m assumming that you’re not on a FFS schedule and either are capitated/salaried. Herein lies a key point: our FFS system sadly encourages over-utilization and a ‘volume-based’ mentality. Payment reform is slowly tackling this issue, but it’s really going to take a generation of doctors who are ‘born’ into a capitated or pay-for-performance world to really deliver on CMS triple aim for lowering costs, improving care and improving the patient experience.

We have mainly FFS, but also have full schedules. The incremental increase in income I get for bringing people in for unnecessary care is minimal. I personally think people are more willing to come in when they don’t think I am trying to milk money out of them. I have a full schedule and have business enough without generating it through making people come in too often. The downside of capitated care is that people devalue the service. HMO’s got people believing that I was worth only a $10 copay. There are other solutions, but I’ll discuss that in future posts.

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Bill Springer

Aug 14, 2012

Excellent analogy using the GPS, Dr. Lamberts! I too have been guided far off the proper track by relying mindlessly on technology when not filtered by common sense and experience. I applaud your willingness to explore how best to position primary care in the brave new world of online health technology.

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LindaB

Aug 14, 2012

This was a very well-written article, and I agree with the author; while patients are now empowered with information regarding either traditional or complementary/alternative medicine, it is still better for their health if they consult a qualified healthcare professional before making decisions that may have negative consequences. Also, I encourage those who want to do their own research to seek out databases that give unbiased information that is based on clinical research…if it is too complex to read, it is better to ask for help than to choose something that is written in more simple terms, because it may mean that the author of the article is not a qualified healthcare professional, but a layperson.

As a specialist, I have a lot of respect for the primary care profession. And I think your concern is absolutely right. There is such a large breadth of knowledge that an internist needs to have that it is a waste to spend all of the energy on the colds and more common problems. There is real nuance and knowledge that great primary providers can provide that gets wasted on the low level issues. It’s annoying to me as a specialist, so I imagine it is incredibly aggravating for the internist or family physician.

And the funny thing about protocols – and I say this as both a doctor and having been a patient – we really need experienced (not just book read or algorithm based) caregivers who can give us context and understanding and guide us in our learning and in our decision process. And while the benefits of technology – for data management and intervention, as well as smart decision tools – are hugely valuable, anyone who disparages the value of good nurses or doctors only has to get sick once to understand the limits of technology.

This is like when carpenters and plumbers were going to be put out of business by Home Depot, Lowe’s and the whole DIY construction industry. Fast forward a few years, and all of these providers are doing fine. Why? Because people went out, read a book, bought tools and products, and took on their DIY projects, only to muck up many of them and then have to spend more time, money and energy in getting the professionals to fix them. The problem we keep making in society is having humans do the work that technology can often automate more easily, and having technology do what people can actually do better and with nuance that technology just cannot provide.

I think your analogy is right on, although I think we do more than clean up their messes. I think our job is to be the ones who know the house, who understand the wood, who open ourselves to keep them from being electrocuted, impaled, or crushed under their falling roofs. Of all health care professionals, we are still the most familiar and the most trusted. Again, why not give up the colds and the following of rote protocols and take up a bigger task?

Nice post. We have made ourselves too small, for the most part, because of the payment system. It would be great to spend time helping patients navigate the health care system and be their personal advisors, getting to know them well over time. But it’s hard to get paid adequately for that, at least in the traditional insurance based system under which most of us practice.

A smaller panel size with time to fully address patient concerns, provide adequate education, talk with specialists, research pertinent issues, etc. is a utopian vision that reality has annihilated. So instead we keep stuffing our schedules, running around like chickens with no heads, treating coughs, following protocols, and buffing up the chart, burying any useful information under a mound of jibberish.

Well said:
“So instead we keep stuffing our schedules, running around like chickens with no heads, treating coughs, following protocols, and buffing up the chart, burying any useful information under a mound of jibberish”
Why defend that part of our job that we hate? Let them have what they want, and let us use our expertise as PCP’s to act as curators of information and guides along the way. It may actually be a better life.

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